Basic Information
| Provider Information | |||||||||
| NPI: | 1942305107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASTIEN | ||||||||
| FirstName: | MARIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 FOX CT | ||||||||
| Address2: | |||||||||
| City: | HAINESPORT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080364807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565189578 | ||||||||
| FaxNumber: | 6095189579 | ||||||||
| Practice Location | |||||||||
| Address1: | 3111 ROUTE 38 | ||||||||
| Address2: | BLDG 11 PMB 104 | ||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080549754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092615755 | ||||||||
| FaxNumber: | 6092617199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 25MA07793000 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.